Continuum of Care Rental Payment Form

CLIENT RENTAL PAYMENT:

NOTICE: Payments made on this page are for Rent Payments for programs provided by Continuum of Care, headquartered at 109 Legion Ave, New Haven, Connecticut 06519. If you are attempting to make a payment for services outside of Connecticut, you are on the wrong website.
Are you attempting to make a rental payment for services provided outside of Connecticut?
If you select YES, you are on the wrong website. This site is only for services provided by Continuum of Care in the state of Connecticut. Please go back and double check which organization you are trying to make a payment to.
Client Information
Client's Name

First NameLast Name
Client's Program Address at Continuum

Street Address

Street Address Line 2

CityState

Zip Code
Billing Contact Information
Name of Billing Contact (Client or Conservator):
Billing Contact's Email
example@example.com
Phone Number of Billing Contact

Area CodePhone Number (no dash)
Billing Contact's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

One Time Rental Payment(USD one-time payment)

Recurrent Monthly Payment Amount(USD for each month)

Monthly Payment

Comments
Indicate what are you paying, for example the invoice number or service provided
Signature: (by signing below, I authorize Continuum of Care, Inc. to charge my account as indicated above for the amount listed. I understand that I may cancel this authorization at any time with written notice):
Should be Empty:

CLIENT RENTAL PAYMENT: